Basic Research—Technology

A Comparative Scanning Electron Microscopic Investigation

of the Smear Layer after the Use of Sodium Hypochlorite Gel
and Solution Forms as Root Canal Irrigants
Vahid Zand, DDS, MSc,* Mehrdad Lotfi, DDS, MSc,* Saeed Rahimi, DDS, MSc,*
Hadi Mokhtari, DDS, MSc,* Ali Kazemi, DDS,* and Vahideh Sakhamanesh, DDS†

Abstract
Introduction: The effect of sodium hypochlorite
(NaOCl) gel along with EDTA on the removal of the smear
layer has not been studied; therefore, the aim of the
S uccessful endodontic therapy requires shaping and cleaning of root canal systems
(1). During canal preparation of infected teeth, special attention must be given to
the elimination of bacteria and their toxins from the root canal system (2). The smear
present study was to compare the efficacy of gel and layer is produced during root canal preparation by the manipulation of the surface
solution forms of NaOCl in removal of the smear layer elements of the dentinal walls of canals. It is believed, from a biologic point of view,
from root canal walls. Methods: A total of 40 single- that the presence of a smear layer contributes to leakage, and it is a source of nutrients
rooted teeth with minimum curvature (<5 ) were for microorganisms (3).
selected and divided into two experimental groups, One of the most popular root canal irrigants is sodium hypochlorite (NaOCl)
each containing 15 teeth and one positive control group because of its physicochemical and antibacterial properties (2). NaOCl has the unique
containing 10 teeth. The canals of all the teeth were capacity to dissolve necrotic tissue and the organic components of the smear layer (4).
prepared with rotary RaCe instruments up to #35. In However, there are some disadvantages for NaOCl. It is toxic to tissues, causing hemo-
the NaOCl solution group, the root canals were flushed lysis, ulceration, and inhibition of neutrophil migration; it results in damage to endo-
with 2.5% NaOCl solution during instrumentation and in thelial and fibroblast cells, facial nerve weakness, allergic reaction, and necrosis after
NaOCl gel group, the instruments were coated with gel extrusion during root canal treatment (5). NaOCl is an alkaline solution with a pH of
form of NaOCl and used inside the root canals; then approximately 11 to 12. It causes injury primarily by oxidation of proteins. Heggers
saline was used for root canal irrigation. Finally, 1 mL et al studied the toxic effects of NaOCl and found that at a concentration of 0.025%,
of 17% EDTA was used to rinse inside the root canals the solution was both bactericidal and nontoxic. However, at a concentration of
and remained in the root canals for 2 minutes in the 0.25%, the solution became significantly toxic to tissues. They found severe inflamma-
both experimental groups; in the saline group, only tion and cellular destruction in all tissues except for heavily keratinized epithelium (6).
saline was used for irrigation. The amount of the smear Inadvertent injection of sodium hypochlorite beyond the apical foramen may
layer was quantified according to the Torabinejad occur in teeth with wide apical foramina or when the apical construction has been de-
method using a scanning electron microscope. Data stroyed during root canal preparation or by resorption. In addition, extreme pressure
were analyzed by the Kruskal-Wallis and Mann- during irrigation or binding of the irrigation needle tip in the root canal may result in
Whitney tests. All the statistical analyses were set with contact of large volumes of the irrigant with the apical tissues (7). If this occurs, excel-
a significance level of a = 0.05. Results: There were lent tissue-dissolving capacity of NaOCl will lead to tissue necrosis (7). The use of the gel
no significant differences between NaOCl gel and solu- form of NaOCl can reduce the risk of extrusion of NaOCl into periapical tissues. The
tion forms in the coronal, middle, and apical thirds of effect of NaOCl gel along with EDTA on the removal of the smear layer has not been
root canals. There were significant differences between studied; therefore, the present study tested the hypothesis that a gel formulation of
NaOCl solution and saline groups in the three parts of 2.5% NaOCl as a lubricant accompanied with saline is as effective as 2.5% NaOCl solu-
root canal walls and between NaOCl gel and saline in tion in removing the smear layer when 17% EDTA is used as a final rinse.
the coronal, middle, and apical thirds. Conclusion:
The use of NaOCl gel can be as effective as NaOCl solu-
tion along with EDTA in smear layer removal in the three Materials and Methods
parts of root canal walls. (J Endod 2010;36:1234–1237) A total of 40 extracted human anterior single-rooted teeth with mature apices and
minimum curvature (<5 ) were selected for the purpose of this study. The degree of
Key Words canal curvature was determined using the Schneider method (8). After access cavity
EDTA, NaOCl, scanning electron microscope, smear preparation, the pulp tissues were removed with a barbed broach (Dentsply, Maillefer,
layer Switzerland), and the size of the apical foramen was gauged with a #15 K-file (Dentsply,

From the *The Department of Endodontics,Tabriz Dental School,Tabriz University of Medical Sciences, Tabriz, Iran; and †Private Practice, Tabriz, Iran.
Address requests for reprints to Dr Mehrdad Lotfi, Department of Endodontics, Tabriz Dental School, Tabriz University of Medical Sciences, Tabriz, Iran. E-mail
address: [email protected].
0099-2399/$0 - see front matter
Copyright ª 2010 American Association of Endodontists.
doi:10.1016/j.joen.2010.02.033

1234 Zand et al. JOE — Volume 36, Number 7, July 2010

 Basic Research—Technology
Maillefer, Switzerland). The teeth were then randomly divided into two
experimental groups, each containing 15 teeth and one positive control
group containing 10 teeth.
The working length was determined by measuring the length of the
initial file (#10) at the apical foramen minus 1 mm in all the groups. The
apical part of the roots was put inside green stick compound during
instrumentation. The canals of all the teeth were prepared up to file
#35. Each instrument was used only in three canals and then was re-
placed by a new one.
Instrumentation was performed by using RaCe rotary instruments
(FKG; Dentaire, La-Chaux-de-Fonds, Switzerland). These instruments
were set into rotational speed (500 rpm) with an eight:one reduction
handpiece powered by a torque limited electric motor (TCM Motor
3000; Novage, Konstanz, Germany). Instrumentation was completed using
the crown-down technique according to the manufacturer’s instructions.
The preparation sequence was as follows: (1) 0.1 tapered #40
instruments were used to one third of the working length, (2) 0.08
tapered #35 instruments were used to one half of the working length,
(3) 0.06 tapered #25 instruments were used to two thirds of the
working length, (4) 0.04 tapered #30 instruments were used to the
full working length, and (5) 0.04 tapered #35 instruments were used
to the full working length. During instrumentation, root canals in the
three groups were flushed with different irrigation protocols as follows:
In the NaOCl solution group, the root canals were flushed with 5
mL of 2.5% NaOCl (Pakshoma, Tehran, Iran) during instrumentation,
and at the end of preparation 1 mL of 17% EDTA (Merck, Darmeshtadt,
Germany) was used as the irrigation solution, which was left in the
canals for 2 minutes. At the end of instrumentation, 5 mL of distilled
water was used as final rinse.
In the NaOCl gel group, gel form of 2.5% NaOCl was used. Instru-
ments were coated with the gel form of NaOCl during instrumentation
and used inside the root canals. During instrumentation, canals were irri-
gated with saline after introducing each instrument. One milliliter of 17%
EDTA was used as a final irrigant, which remained in the canal for 2
minutes. Finally, 5 mL of distilled water was used for the final irrigation.
In the saline group, saline was used for root canal irrigation in the
positive control group during instrumentation, and 1 mL of distilled
water was used as a final irrigant and 5 mL of distilled water was
used as final rinse.

Evaluation
All root canal preparations were completed by one operator,
whereas the scanning electron microscope (SEM) evaluations were
performed by two other examiners who were blind to the experimental
groups.

Canal Cleanliness
After preparation, two longitudinal grooves were prepared on the
buccal and lingual aspects of the teeth using a #1 diamond disk (D&Z,
Diamant, Germany). The grooves were not deep enough to enter the
canals. A plastic instrument was then used to separate the teeth into
two halves, and both halves were prepared for SEM evaluation under
an LEO 360 SEM (Leo Electron Microscopy, Cambridge, UK) at
1,000 magnifications. Photomicrographs from the approximate
center of the coronal, middle, and apical thirds were exposed at
1,000 for each specimen. Two endodontists scored the presence Figure 1. (A) Comparison of the smear layer in the coronal third of the root
or absence of the smear layer in a blind manner. The images were canals between the three groups. (B) Comparison of the smear layer in the
scored according to the following criteria reported by Torabinejad et middle third of the root canals between the three groups. (C) Comparison
al (9): (1) no smear layer: no smear layer on the surface of the root of the smear layer in the apical third of the root canals between the three
groups. (This figure is available in color online at www.aae.org/joe/.)
canal and all the tubules clean and open; (2) moderate smear layer:
no smear layer on the surface of the root canal, but tubules containing

JOE — Volume 36, Number 7, July 2010 SEM Investigation of the Smear Layer after Use of NaOCl as Root Canal Irrigants 1235
Basic Research—Technology

Figure 2. (A) The canal wall after using NaOCl solution, the clean canal wall in the coronal third of the prepared canal (score 1). (B) The canal wall after using
NaOCl gel, the clean canal wall in the middle third of the prepared canal (score 1). (C) The canal wall after using saline, complete coverage of the canal wall with the
smear layer in the apical third of the canal (score 3).

debris; and (3) heavy smear layer: smear layer covering the root canal direction may result in contact of large volumes of the irrigant with
surface and the tubules. the apical tissues (7). This study was conducted to test the hypothesis
Data were analyzed by the Kruskal-Wallis test and the Mann- that a gel form of 2.5% NaOCl as a lubricant accompanied with saline
Whitney rank sum test for pair-wise comparisons. All the statistical anal- is as effective as 2.5% NaOCl solution in removing the smear layer
yses were set with a significance level of a = 0.05. from instrumented root canal walls.
The gel form of NaOCl was prepared by adding 2.5% NaOCl to
a water-soluble vehicle (polypropylene and polyethylene glycol). There-
Results fore, the gel is completely soluble in water. Each instrument used in the
The results for smear layer removal are presented in Figure 1A canal was coated with this gel as a lubricant, and then the root canals
through C. These figures show the mean ranks for the smear layer re- were irrigated with saline for flushing the remaining NaOCl gel and
maining in the coronal, middle, and apical thirds of the root canals with debris out of the root canal. Figure 2A through C shows the photomi-
three different irrigation regimens. The Kruskal-Wallis test showed crographs of coronal, middle, and apical thirds of root canal walls.
significant differences among irrigation solutions in the coronal, As stated previously, none of the irrigation regimens used
middle, and apical thirds (p = 0.004, p < 0.001, and p = 0.012, respec- completely removed the smear layer from the root canal. This finding
tively). The Mann-Whitney rank sum test for pair-wise comparisons did is consistent with the results of other studies (14, 15). However, we
not reveal any significant differences between NaOCl solution and gel did not find any significant differences between NaOCl solution and
groups in the coronal (Figs. 1A and 2A), middle (Figs. 1B and 2B), gel in the three parts of the root canal walls, which shows that the
and apical (Figs. 1C and 2C) thirds of the root canal walls (p = 0.68, use of NaOCl gel can be effective in smear layer removal and we can
p = 0.87, and p = 0.51, respectively); however, there were significant eliminate the side effects of NaOCl solution with the use of NaOCl gel.
differences between NaOCl solution and saline groups in the coronal, Other investigators such as Antonio et al (16) and Rahmann et al
middle, and apical thirds of the root canals (p = 0.016, p < 0.001, (17) used Carisolve (Med Team, Goteborg, Sweden) as a root canal ir-
and p = 0.012, respectively) and between NaOCl gel and saline groups rigant without any significant effectiveness in smear layer removal. Car-
in the coronal, middle, and apical thirds (p < 0.001, p < 0.001, isolve is a gel form of 0.05% NaOCl that is advocated for
p = 0.045, respectively). More smear layer was observed in the saline chemomechanical removal of infected carious dentin (18). Rahman
group in comparison with NaOCl gel and solution groups. et al used Carisolve for 30 minutes in the immature root canal and
concluded that it is as effective as 1% NaOCl. We used 2.5% NaOCl
Discussion gel during root canal instrumentation without spending any extra
The choice of an irrigant is of great importance because there are time for its effect, which is very close to clinical situations. Unsuccessful
differences in their efficacy to act as lubricants during instrumentation results of using Carisolve in the Antonio et al study might be attributed to
to flush debris, smear layer, and bacteria out of the canal. Different the low concentration of NaOCl in Carisolve.
chemical formulations of irrigants might have different reactions on The results of this study show that using NaOCl gel in combination
the pulp and periapical tissues, leading to tissue necrosis (10). with the flushing effect of saline when EDTA 17% is used as a final rinse
NaOCl is an effective endodontic irrigation solution in a variety of can be effective in removing the smear layer. Studies on the antibacterial
concentrations, ranging from 0.5% to 6% (7, 11). However, it may effect of NaOCl gel can be helpful if NaOCl gel is to be suggested in root
cause serious complications because of incorrect use or mistakes. canal instrumentation.
The most common complication is accidental injection into the
periapical tissues in teeth with immature apical foramina or when the
apical constriction has been destroyed during root canal preparation Conclusion
or by resorption (11–13). In addition, extreme pressure during On the basis of the results of the present study, it can be concluded
irrigation or binding of the irrigation needle tip in the root canal with that NaOCl gel can be effective in removing the smear layer, and the side
no escape route for the irrigant to leave the root canal in a coronal effects of NaOCl solution can be avoided with the use of NaOCl gel.

1236 Zand et al. JOE — Volume 36, Number 7, July 2010

 Basic Research—Technology
References 10. Murray PE, Farber RM, Namerow KN, et al. Evaluation of Morinda citrifolia as an
endodontic irrigant. J Endod 2008;34:66–70.
1. Hales JJ, Jackson CR, Everett AP, et al. Treatment protocol for the management of 11. Zehnder M, Kosicki D, Luder H, et al. Tissue-dissolving capacity and antibacterial
a sodium hypochlorite accident during endodontic therapy. Gen Dent 2001;49: effect of buffered and unbuffered hypochlorite solutions. Oral Surg Oral Med
278–81. Oral Pathol Oral Radiol Endod 2002;94:756–62.
2. Gernhardt CR, Eppendorf K, Kozlowski A, et al. Toxicity of concentrated sodium 12. Sabala CL, Powell SE. Sodium hypochlorite injection into periapical tissues. J Endod
hypochlorite used as an endodontic irrigant. Int Endod J 2004;37:272–80. 1989;15:490–2.
3. Zand V, Bidar M, Ghaziani P, et al. A comparative SEM investigation of the smear 13. Witton R, Brennan PA. Severe tissue damage and neurological deficit following
layer following preparation of root canals using nickel titanium rotary and hand extravasation of sodium hypochlorite solution during routine endodontic treatment.
instruments. J Oral Sci 2007;49:47–52. Br Dent J 2005;198:749–50.
4. Zehnder M. Root canal irrigants. J Endod 2006;32:389–98. 14. Bolanos OR, Jensen JR. Scanning electron microscope comparisons of the efficacy
5. Pontes F, Pontes H, Adachi P, et al. Gingival and bone necrosis caused by accidental of various methods of root canal preparation. J Endod 1980;6:815–22.
sodium hypochlorite injection instead of anaesthetic solution. Int Endod J 2008;41: 15. Hulsmann M, Rummelin C, Schafers F. Root canal cleanliness after preparation with
267–70. different endodontic handpieces and hand instruments: a comparative SEM investi-
6. Mehra P, Clancy C, Wu J. Formation of a facial hematoma during endodontic gation. J Endod 1997;23:301–6.
therapy. J Am Dent Assoc 2000;131:67–71. 16. Antonio AG, Maia LC, Primo LG, et al. The role of Carisolv and different auxiliary
7. Hülsmann M, Hahn W. Complications during root canal irrigation—literature chemical substances in the removal of bovine root canal smear layer. J Oral Sci
review and case reports. Int Endod J 2000;33:186–93. 2006;48:99–103.
8. Schnieder Sw A. Comparison of canal preparations in straight and curved root 17. Rahman S, Whitworth JM, Dummer PM. Carisolve: an alternative to NaOCl in imma-
canals. Oral Surg Oral Med Oral Pathol 1971;32:271–5. ture root canals? Int Endod J 2005;38:448–55.
9. Torabinejad M, Khademi AA, Babagoli J, et al. A new solution for the removal of the 18. Beeley JA, Yip HK, Stevenson AG. Chemochemical caries removal: a review of the
smear layer. J Endod 2003;29:170–5. techniques and latest developments. Br Dent J 2000;188:427–30.

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